Validation of the Spanish version of DYsphagia in MUltiple Sclerosis questionnaire (DYMUS).

BACKGROUND: Dysphagia is a common symptom in multiple sclerosis that can occur even early in the disease course and can lead to serious complications. Early recognition and treatment can promote comfort, safety and optimal nutritional status. Few dysphagia rating scales are available in Spanish. The aim of this study was to translate the Dysphagia in Multiple Sclerosis Questionnaire (DYMUS) into Spanish and to validate it. METHODS: Forward and backward translation method was used to translate the original English version of DYMUS into Spanish. A pilot-study with 10 PwMS was carried on in order to improve the intelligibility of the instrument, comprehensibility and content validity of the questionnaire. The questionnaire was filled out by 100 PwMS who were asked a dichotomous question on their swallowing ("Do you have swallowing troubles?"). Descriptive data are presented as median and quartiles for continuous variables and frequency and percentage for categorical ones. Internal consistency reliability was estimated by Cronbach's alfa. Test-retest reliability was estimated by intraclass correlation coefficient. Concurrent validity with a speech and language therapy assessment (SLT-A) was measured with the weighted kappa statistic for the concordance for both dysphagia type and degree categories. Confirmatory factor analysis by means of structural equation models was used to verify the two-factor (solids and liquids) structure of the DYMUS questionnaire. As the goodness of fit evaluation was poor, an additional exploratory factor analysis was carried out. RESULTS: Internal consistency was high. The globus sensation question and the weight loss questions (item 3 and 10) are the least specific with dysphagia symptomatology so they are worst correlated with the sum of the others (item-rest correlation, 0.243 and 0.248, respectively). The test-retest reliability of the DYMUS among 40 patients using ICC was 0.75 (95% CI 0.57 - 0.86). Concurrent validity with SLT-A was poor (weighted kappa 0.37 for dysphagia type and 0.38 for dysphagia degree). The DYMUS questionnaire detected three times more dysphagia (53% versus 17%) than the dichotomous question. Confirmatory factors analysis failed to confirm the bidimensional structure (solid and liquid items) often reported in other validation studies. The subsequent exploratory factor analysis also identified two factors, but with poor interpretability. CONCLUSION: DYMUS-SP scale is not a sufficiently useful scale to detect dysphagia in PwMS due to the poor concurrent validity and the probable overdiagnosis of the condition; however, it can be helpful as a screening tool when combined with other measures.

Disfagia orofaríngea en el ictus: aspectos diagnósticos y terapéuticos / Oropharyngeal dysphagia in stroke: diagnostic and therapeutic aspects

INTRODUCCIÓN: La disfagia orofaríngea tiene una elevada prevalencia tras un ictus. Se manifiesta clínicamente en alteraciones en la eficacia y la seguridad de la deglución, con la consiguiente morbimortalidad asociada a las alteraciones nutricionales y respiratorias. OBJETIVO: Efectuar una revisión actualizada de los aspectos diagnósticos y terapéuticos de la disfagia orofaríngea tras un ictus, con aplicabilidad en la clínica diaria, y de las técnicas de neuroestimulación no invasiva. DESARROLLO: El proceso de diagnóstico y tratamiento de la disfagia orofaríngea tiene como objetivos cribar, identificar y diagnosticar a los pacientes con riesgo de disfagia, e instaurar las medidas dietéticas y terapéuticas que aseguren la correcta nutrición e hidratación de los pacientes en condiciones de seguridad. El diagnóstico se basa en la exploración clínica de la deglución y en las exploraciones instrumentales, como la videofluoroscopia y la fibroendoscopia. Las medidas terapéuticas incluyen las estrategias compensadoras y rehabilitadoras (maniobras activas, ejercicios de control motor, electroestimulación neuromuscular y tratamiento con toxina botulínica). Las técnicas de neuroestimulación incluyen la estimulación central no invasiva y la estimulación eléctrica intrafaríngea. CONCLUSIÓN: La disfagia orofaríngea tiene una elevada prevalencia tras un ictus. El diagnóstico debe incluir una evaluación clínica y una exploración instrumental, y así indicar de forma objetiva el tratamiento, que incluirá medidas compensadoras y restauradoras con las que reducir la morbimortalidad asociada

INTRODUCTION. The prevalence of oropharyngeal dysphagia is high after a stroke. Clinically, it manifests as alterations affecting swallowing efficiency and safety, with the consequent morbidity and mortality associated with nutritional and respiratory alterations. AIM. To carry out an updated review of the diagnostic and therapeutic aspects of oropharyngeal dysphagia after a stroke that can be applied in daily clinical practice, and of the non-invasive neurostimulation techniques. DEVELOPMENT: The process of diagnosis and treatment of oropharyngeal dysphagia aims to screen, identify and diagnose patients at risk of dysphagia, and establish the dietary and therapeutic measures that ensure proper nutrition and hydration of patients under safe conditions. The diagnosis is based on the clinical examination of swallowing and on instrumental examinations such as videofluoroscopy and fibro-endoscopy. Therapeutic measures include compensatory and rehabilitative strategies (active manoeuvres, motor control exercises, neuromuscular electrostimulation and botulinum toxin treatment). Neurostimulation techniques include non-invasive central stimulation and intrapharyngeal electrical stimulation. CONCLUSION: The prevalence of oropharyngeal dysphagia is high after a stroke. Diagnosis should include a clinical evaluation and an instrumental examination, and thus objectively indicate the treatment, which will include compensatory and restorative measures with which to reduce the associated morbidity and mortality

Prevalence of medication and off-label medication use in acquired brain injury at a neurorehabilitation hospital.

PURPOSE: Patients who suffer acquired brain injury (ABI) require a great variety of drugs. Furthermore, the lack of evidence on the medication effects in this type of patient increases off-label prescription. The aim of this study was to describe the pattern of medication use and the practice of prescribing off-label drugs in these patients. METHODS: A cross-sectional study was conducted in patients with ABI, of either traumatic or non-traumatic cause, admitted to a neurorehabilitation hospital for rehabilitation. Demographic and clinical data and prevalence of medication use and off-label prescription were collected. RESULTS: The majority of the studied patients (85.2%) were considered polymedicated since they were prescribed ≥ 6 drugs concomitantly. In traumatic brain injury (TBI) patients, antidepressants (81.5%) were the Anatomical Therapeutic Chemical (ATC) group's most prescribed versus antithrombotic agents (80.5%) in non-traumatic brain injury (N-TBI) patients. Up to 37.3% of all active substances prescribed in TBI patients were off-label compared with 24.9% in N-TBI patients. The most prescribed off-label active substances in both groups were those related to the Nervous System (N) ATC group to treat neurobehavioural problems. CONCLUSION: A multidisciplinary pharmacotherapeutic follow-up of these patients would be essential to address the high prescription rate of medications and the off-label prescription practice. In this way, medication problems related to polypharmacy could be minimised and the benefit-risk ratio of prescribed off-label drugs could be ensured according to the available medical evidence.

Neurorehabilitation strategies for poststroke oropharyngeal dysphagia: from compensation to the recovery of swallowing function.

Oropharyngeal dysphagia (OD) is very prevalent among poststroke patients, causing severe complications but lacking specific neurorehabilitation treatment. This review covers advances in the pathophysiology, diagnosis, and physiologically based neurorehabilitation strategies for poststroke OD. The pathophysiology of oropharyngeal biomechanics can be assessed by videofluoroscopy, as delayed laryngeal vestibule closure is closely associated with aspiration. Stroke may affect afferent or efferent neuronal circuits participating in deglutition. The integrity of oropharyngeal-cortical afferent pathways can be assessed by electroencephalography through sensory-evoked potentials by pharyngeal electrical stimulation, while corticopharyngeal efferent pathways can be characterized by electromyography through motor-evoked potentials by transcranial magnetic stimulation. Dysfunction in both cortico-mediated evoked responses is associated with delayed swallow response and aspiration. Studies have reported hemispherical asymmetry on motor control of swallowing and the relevance of impaired oropharyngeal sensitivity on aspiration. Advances in treatment include improvements in compensatory strategies but are mainly focused on (1) peripheral stimulation strategies and (2) central, noninvasive stimulation strategies with evidence of their clinical benefits. Characterization of poststroke OD is evolving from the assessment of impaired biomechanics to the sensorimotor integration processes involved in deglutition. Treatment is also changing from compensatory strategies to promoting brain plasticity, both to recover swallow function and to improve brain-related swallowing dysfunction.

How does dysautonomia influence the outcome of traumatic brain injured patients admitted in a neurorehabilitation unit?

BACKGROUND: Patients surviving severe traumatic brain injury (TBI) may suffer from symptoms presumed to be related to an excessive sympathetic production known as paroxysmal sympathetic hyperactivity (PSH). While this condition is more common in the acute phase, prognosis is less clear in rehabilitation settings. AIM: The goal of this study is to describe the functional status of patients with PSH admitted in a rehabilitation hospital and to determine its prognostic influence during rehabilitation. METHODS: A cohort study was undertaken of all the patients admitted in a neurorehabilitation hospital suffering from PSH. Functional outcomes were reported according to the Glasgow outcome scale-extended (GOSE), the Disability Rating Scale (DRS) and the Functional Independence Measure (FIM). RESULTS: Thirteen out of 39 patients suffered symptoms compatible with PSH. Neuroimaging of PSH patients showed more diffuse lesions. The FIM at admission was lower in the PSH group who was transferred for rehabilitation at an earlier stage. At discharge no differences were seen using the FIM, DRS and GOS-E. CONCLUSIONS: Functional status is similar and PSH does not appear to influence recovery during the rehabilitation, although PSH patients are more likely to undergo psychoactive medications and special care is needed to approach their caregivers that perceive PSH as a complication for rehabilitation.

Tratamiento con electroestimulación neuromuscular de la disfagia orofaríngea en pacientes con ictus / Treatment of oropharyngeal dysphagia with neuromuscular electrostimulaiton

Fundamento y objetivo: La disfagia orofarínge a es muy prevalente en pacientes con ictus, con una elevada morbimortalidad asociada. La electroestimulación neuromuscular (EENM) es un nuevo tratamiento potencialmente útil. El objetivo de este estudio fue valorar la eficacia terapéutica y la seguridad de la EENM en el tratamiento de la disfagia orofaríngea en pacientes con ictus. Pacientes y método: Estudio prospectivo de 9 pacientes con ictus, con aspiración traqueal confirmada mediante exploración videofluoroscópica (VDF), tratados con el tratamiento convencional de la disfagia orofaríngea junto con EENM. Se realizó seguimiento al finalizar el tratamiento con EENM y a los 3 meses. Resultados: El número medio de sesiones efectuadas fueron 18 (intervalo 15-20), con una intensidad media de estimulación de 12,45mA (intervalo 6,6-16,7mA). Antes del tratamiento 8 pacientes se alimentaban exclusivamente por sonda de gastrostomía; tras el mismo únicamente un paciente persistía con alimentación exclusiva por sonda de gastrostomía. Ningún paciente presentó complicaciones. Los parámetros VDF previos al tratamiento, tiempo de tránsito oral, disparo del reflejo deglutorio (DRD) y tiempo de tránsito faríngeo, estaban alargados y el ascenso hioideo reducido. Después del tratamiento se redujo a 6 el número de pacientes con aspiración traqueal, pero únicamente en 3 persistía para las 3 viscosidades estudiadas (líquido, néctar y pudin), objetivándose una mejoría global en los parámetros VDF. El único factor predictivo de efectividad terapéutica fue el retraso en el DRD (AU)

Background and objective: Oropharyngeal dysphagia is highly prevalent in stroke patients, with a high mortality and morbidity. Neuromuscular electro stimulation (NMES) is a new and potentially useful therapy. We assessed the therapeutic effectiveness and safety of NMES in the treatment of or pharyngeal dysphagia in patients with stroke. Patients and method: Prospective study of stroke patients, with tracheal aspiration revealed by videofluoroscopy (VDF), who underwent conventional therapy of or pharyngeal dysphagia as well as NMES. We did a follow-up at the end of the treatment and 3 months later. Results: Patients underwent 18 courses of treatment (15-20) with a mean stimulation intensity of12.45 mA (range: 6.6-16.7 mA). Before starting therapy, 8 patients were fed exclusively by means of a gastrostomy tube; after the treatment, only one patient needed it. No patient had complications. VDF parameters before treatment: oral transition time, swallowing reflex shooting (SRS) and pharyngeal transition time were longer and the hyoid elevation was reduced. After the treatment, the number of patients with tracheal aspiration decreased to 6, but only in 6 it persisted for the three analyzed viscosities (liquid, nectar and pudding), with an overall improvement of the VDF parameters. The only predictive factor of therapeutic effectiveness was the delay in the SRS. Conclusion: NMES is an effective and safe treatment for stroke patients with or pharyngeal dysphagia (AU)

[Treatment of oropharyngeal dysphagia with neuromuscular electrostimulaiton]. / Tratamiento con electroestimulación neuromuscular de la disfagia orofaríngea en pacientes con ictus.

BACKGROUND AND OBJECTIVE: Oropharyngeal dysphagia is highly prevalent in stroke patients, with a high mortality and morbidity. Neuromuscular electrostimulation (NMES) is a new and potentially useful therapy. We assessed the therapeutic effectiveness and safety of NMES in the treatment of oropharyngeal dysphagia in patients with stroke. PATIENTS AND METHOD: Prospective study of stroke patients, with tracheal aspiration revealed by videofluoroscopy (VDF), who underwent conventional therapy of oropharyngeal dysphagia as well as NMES. We did a follow-up at the end of the treatment and 3 months later. RESULTS: Patients underwent 18 courses of treatment (15-20) with a mean stimulation intensity of 12.45mA (range: 6.6-16.7mA). Before starting therapy, 8 patients were fed exclusively by means of a gastrostomy tube; after the treatment, only one patient needed it. No patient had complications. VDF parameters before treatment: oral transition time, swallowing reflex shooting (SRS) and pharyngeal transition time were longer and the hyoid elevation was reduced. After the treatment, the number of patients with tracheal aspiration decreased to 6, but only in 6 it persisted for the three analyzed viscosities (liquid, nectar and pudding), with an overall improvement of the VDF parameters. The only predictive factor of therapeutic effectiveness was the delay in the SRS. CONCLUSION: NMES is an effective and safe treatment for stroke patients with oropharyngeal dysphagia.

Resolution of tracheal aspiration after the acute phase of stroke-related oropharyngeal Dysphagia.

OBJECTIVES: We set out to ascertain the evolution and the clinical and videofluoroscopic (VFS) prognostic factors of aspiration recovery and return to oral intake in patients with stroke and VFS diagnosis of tracheal aspiration. METHODS: Twenty patients with stroke and VFS diagnosis of tracheal aspiration were prospectively evaluated. Clinical evaluation of oropharyngeal dysphagia and VFS examination were performed at admission and repeated at 1, 3, 6 and 12 months of follow-up. RESULTS: At admission, videofluoroscopy showed 40% of patients to have an increase in oral transit time and 65% impaired tongue control; in the pharyngeal phase, mean pharyngeal transit time was increased in 70% of patients and the time required to trigger the swallowing reflex was delayed in 70%. During follow-up, an improvement was observed, and the number of patients with aspiration decreased progressively (the most significant change occurred at 6 months). Evolution was related to the vascular territory affected: at 1 year, aspiration persisted in 12% of anterior territory lesions vs. 58% of posterior territory lesions. Also, the number of silent aspirators decreased from 35% at baseline to no patients after 3 months. Persistent aspiration at 1 year of follow-up significantly correlated with the following baseline variables: vascular territory, gag reflex abolition, palatoglossal seal alteration and pharyngeal delay time. CONCLUSIONS: Swallowing physiology in stroke greatly improved during follow-up, mainly between 3 and 6 months, and the number of aspirations decreased progressively. Prognostic factors for persisting aspiration are posterior vascular territory lesions, oropharyngeal reflex abolition, palatoglossal seal alteration and pharyngeal delay time at baseline.

Long-lasting effect of a single botulinum toxin injection in the treatment of oropharyngeal dysphagia secondary to upper esophageal sphincter dysfunction: a pilot study.

OBJECTIVE: To evaluate the efficacy of botulinum toxin (BTX-A) injection in the cricopharyngeus muscle in patients with neurological dysphagia caused by alteration in the upper esophageal sphincter (UES) opening and with preserved pharyngeal contraction. MATERIAL AND METHODS: A prospective pilot study was undertaken in 10 patients (7 brain lesions and 3 cervical spinal cord injuries), with a minimum time-lapse of 6 months from neurological lesion to BTX-A injection. Dysfunction of the UES opening and the presence of pharyngeal contraction were diagnosed by videofluoroscopy (VDF) and esophageal manometry (EM). The BTX-A (100 U) injection was guided by endoscopy. Clinical, VDF, and EM follow-ups were carried out at 3 weeks, 3 and 6 months, and at 1 year post-injection. RESULTS: Prior to treatment, 6 patients were fed by nasogastric tube. VDF showed impairment of the UES opening, residue in pyriform sinuses, and aspiration in all cases. During follow-up, there was a decrease in the number of patients that had aspiration: 3 patients at one year. During swallowing, EM showed a mean UES relaxation of 90% (range: 74.5-100%), residual pressure 3.2 mmHg (range: 0-13 mmHg) and pharyngeal amplitude 52 mmHg (range: 25-80 mmHg). At follow-up, a significant improvement in UES relaxation (98% (89-100%)) and pharyngeal contraction (97 mmHg (35-165 mmHg)) was observed. At 3 months, 6 patients were eating exclusively by mouth. CONCLUSIONS: One single injection of BTX-A in the UES has long-lasting effectiveness in patients with neurological dysphagia caused by alteration in the UES opening and with pharyngeal contraction. Nevertheless, a randomized control trial should be done to confirm these results and rule out the effect of potential spontaneous improvement of neurological injury.

Prospective evaluation of oro-pharyngeal dysphagia after severe traumatic brain injury.

PRIMARY OBJECTIVE: To evaluate clinical, videofluoroscopic findings and clinical evolution of neurogenic dysphagia and to establish the prognostic factors. RESEARCH DESIGN: Prospective cohort study. METHODS AND PROCEDURES: Forty-eight patients with severe traumatic brain injury (TBI) and clinically-suspected oro-pharyngeal dysphagia were studied. Clinical evaluation of oro-pharyngeal dysphagia and videofluoroscopic examination were performed. Clinical evolution was based on feeding mode at discharge, the presence of respiratory complications and body mass index (BMI) at admission and at discharge. MAIN OUTCOMES AND RESULTS: Sixty-five per cent of patients had impaired gag reflex and 44% cough during oral feeding. Videofluoroscopy revealed some type of disorder in 90% of cases: 65% in the oral phase and 73% in the pharyngeal phase (aspiration in 62.5%, being silent in 41%). At discharge, 45% were on normal diet, 27% on a modified oral diet, 14% combined oral intake and gastrostomy feeding and 14% were fed exclusively by gastrostomy. Feeding mode at discharge substantially correlated with RLCF score at admission (p=0.04) and with RLCF (p=0.009) and DRS (p=0.02) scores at discharge. CONCLUSIONS: Aspiration is very frequent in patients with severe TBI, being silent in almost half. Cognitive function evaluated with the RLCF is the best prognostic factor. At discharge, 72% of the patients were on oral food intake despite having severe TBI.

[Bowel dysfunction in patients with spinal cord injury: relation with neurological patterns]. / Alteraciones de la función intestinal en pacientes con lesión medular: relación con las características neurológicas de la lesión.

BACKGROUND AND OBJECTIVE: The study consisted of a clinical evaluation of bowel dysfunction and the relation with neurological patterns in spinal cord injury (SCI). PATIENTS AND METHOD: 109 patients; 30% tetraplegics and 70% paraplegics; ASIA Impairment Scale: 65% A (complete), 12% B (sensitive incomplete), 11% C (motor incomplete with muscle grade <3), 13% D (motor incomplete with muscle grade >or= 3). 83% had spinal sacral reflexes (SSR). An interview and ano-rectal examination were performed. RESULTS: 77% patients required laxatives and 68% digital stimulation; 10% had bowel movements less than thrice a week and 18% spent more than one hour; 27% presented constipation, 31% fecal incontinence, 31% had ano-rectal pathology and 18% had autonomic dysreflexia (AD). Patients ASIA A,B,C with SSR took more suppositories, evacuated less frequently and spent more time than patients without SSR. Tetraplegics ASIA A,B,C had more constipation. Only patients with high level SCI and ASIA A,B,C with SSR had AD. ASIA D patients also needed laxatives, digital stimulation and presented colo-rectal symptoms. CONCLUSIONS: The prevalence of colo-rectal symptoms is high in SCI patients and neurogenic bowel characteristics are related to neurological patterns.

Alteraciones de la función intestinal en pacientes con lesión medular: relación con las características neurológicas de la lesión / Bowel dysfunction in patients with spinal cord injury: relation with neurological patterns

Fundamento y objetivo: Evaluar clínicamente la función intestinal en pacientes con lesión medular y relacionarla con sus características neurológicas. Pacientes y método: Se evaluó a 109 pacientes, de los que el 30% presentaba tetraplejía y el 70%, paraplejía. En cuanto a la gravedad de la lesión según la American Spinal Cord Injury Association (ASIA) Impairment Scale, el 65% se clasificó como A (completa), el 12% como B (incompleta sensitiva), el 11% como C (incompleta motora con balance muscular = 3). El 83% tenía reflejos espinales sacros (RES). Se realizó una entrevista y una exploración anorrectal. Resultados: El 77% de los pacientes necesitaba laxantes y el 68%, tacto rectal; un 10% evacuaba menos de 3 veces por semana y un 18% precisaba más de 1 h para la defecación; el 27% presentaba estreñimiento, el 31%, incontinencia, el 31%, enfermedad anorrectal y el 18%, disreflexia autónoma. Los clasificados como ASIA A, B y C con RES usaban más supositorios, evacuaban con menos frecuencia y necesitaban más tiempo para la evacuación que los pacientes sin RES. Los pacientes con tetraplejía y gravedad ASIA A, B y C presentaban más estreñimiento. Sólo las localizaciones altas de la lesión, con gravedad ASIA A, B, C y RES presentaban disreflexia autónoma. Los pacientes con gravedad ASIA D también precisaban laxantes, tacto rectal y presentaban síntomas colorrectales. Conclusiones: Los síntomas colorrectales son muy prevalentes y las características del intestino neurógeno están relacionadas con el tipo de lesión medular

Background and objective: The study consisted of a clinical evaluation of bowel dysfunction and the relation with neurological patterns in spinal cord injury (SCI). Patients and method: 109 patients; 30% tetraplegics and 70% paraplegics; ASIA Impairment Scale: 65% A (complete), 12% B (sensitive incomplete), 11% C (motor incomplete with muscle grade = 3). 83% had spinal sacral reflexes (SSR). An interview and ano-rectal examination were performed. Results: 77% patients required laxatives and 68% digital stimulation; 10% had bowel movements less than thrice a week and 18% spent more than one hour; 27% presented constipation, 31% fecal incontinence, 31% had ano-rectal pathology and 18% had autonomic dysreflexia (AD). Patients ASIA A,B,C with SSR took more suppositories, evacuated less frequently and spent more time than patients without SSR. Tetraplegics ASIA A,B,C had more constipation. Only patients with high level SCI and ASIA A,B,C with SSR had AD. ASIA D patients also needed laxatives, digital stimulation and presented colo-rectal symptoms. Conclusions: The prevalence of colo-rectal symptoms is high in SCI patients and neurogenic bowel characteristics are related to neurological patterns